Blood Purge

Help for rheumatoid arthritis

For Sandra Rachel, 36, a Dickerson, Md., housewife, the pain and stiffness were almost unbearable. Even dressing required aid. Often the swelling in her joints was so severe that she could not get out of bed before noon. No medications seemed to help. That was a year ago. Today Rachel can dress easily, do household chores and climb up the nine flights of stairs to her doctor's office. Her startling rejuvenation is in part the result of a novel experimental treatment that may eventually help many other victims of severe rheumatoid arthritis as well.

No one knows yet what causes this crippler, which afflicts perhaps 6 million Americans, but it seems to involve the immune system. Some white blood cells--part of the system's defenses--seem to go awry. Possibly because something appears "foreign" to them in the joints, perhaps a virus, they converge at these sites. That causes a chronic inflammation that may erode the cartilage and then the bones, leading to deformity.

To filter these cells out of the blood, or any of the foreign material that may be circulating in it, doctors have been turning to a special blood-separation technique. Used by blood banks for at least a decade and more recently as an experimental therapy for other immune-system disorders like lupus erythematosis, myasthenia gravis and polymyositis, it is somewhat similar to hemodialysis for kidney patients. For three or so hours, the blood is slowly tapped from the body, shunted into a centrifuge, spun and separated into its constituents by weight: heavy red cells sink to the bottom, white cells settle in the middle, platelets and fluid plasma rise to the top. Components can be selectively removed and the rest of the blood returned immediately to the patient.

At Cedars-Sinai Medical Center in Los Angeles, Drs. Daniel Wallace, James Klinenberg and Dennis Goldfinger worked with twelve patients with severe rheumatoid arthritis, for whom medications, including gold and penicillamine, provided no relief. They removed either plasma (a process dubbed plasmapheresis) or the white blood cells called lymphocytes and plasma (lymphoplasmapheresis) in 20 sessions over eleven weeks.

Similarly, at the National Institutes of Health in Bethesda, Md., Drs. John Decker, Jacob Karsh and colleagues treated four patients--including Rachel--with lymphapheresis (removal of only the white blood cells) three times a week for five to six weeks. In all except two Los Angeles patients, the therapy provided startling improvement. Their stiffness and agony was relieved for a period averaging several months. An unexpected observation: some patients seemed to get help from drugs that had not been doing them much good, or were not expected to work.

The treatment is admittedly still expensive (hundreds of dollars per session) and untested for long-term effects. But even as a research tool it may prove valuable. Says Klinenberg: "If we can identify the troublesome factors in the white cells or plasma, maybe we can do something to provide lasting relief or even a cure."

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